Samir Misra

Retroperitoneal teratomas in children

Objective: This paper aims to highlight the clinical features, investigations and treatment of retroperitoneal teratomas condition.Methods: 12 patients (8 females and 4 males, age range-2 months to 14 yrs) of retroperitoneal teratoma admitted to the department of Pediatric Surgery, King George Medical University, Lucknow between 1980 and 2004 were studied. Investigations included hematology, plain X-ray of the abdomen, intravenous urography, ultrasound, computerised tomography (CT) of the abdomen (after 1990, 8 patients), and serum alpha-fetoprotein assay (after 1991, 6 patients, preoperatively). All patients underwent surgery. Serum alpha-fetoprotein assay was used during follow-up to detect recurrence.Results: Majority of the tumors were left pararenal in location. In two patients there was bilateral involvement. In all except one, the tumor could be excised easily preserving the kidneys. In one child with a massive cystic tumor with bilateral involvement, the tumor was marsupialised in the first stage and excised subsequently. One child died postoperatively, the other 11 children are well and there has been no tumor recurrence on follow-up.Conclusions: Retroperitoneal teratomas are uncommon lesions in children mostly arising in close relation to the kidneys. The majority are benign but complete excision is necessary for cure. Even large tumors with bilateral involvement of the retroperitoneum can be excised while preserving adjacent organs. Serum alphafetoprotein assay is a reliable method of detecting recurrence.

Invasive aspergillosis causing small bowel infarction in a patient of carcinoma breast undergoing chemotherapy.

Background To report a 45 year old lady presenting with proximal jejunal gangrene due to invasive Aspergillosis. The patient was undergoing adjuvant chemotherapy for advance carcinoma of breast (Stage IV). Methods The patient was referred to our surgical emergency for acute abdominal symptoms for 6 hours. Histopathology revealed bowel wall necrosis and vascular invasion by Aspergillus Fumigatus. Postoperative recovery was uneventful and the patient received Amphotericin-B (1 mg/kg/day) for invasive aspergillosis. Invasive pulmonary aspergillosis was confirmed by isolating Aspergillus Fumigatus from bronchoalveolar lavage and by a positive circulating galactomannan test (ELISA Assay). Results Detailed history revealed dry cough and two episodes of haemoptesis for 2 weeks. Haemogram and counts revealed anemia and neutropenia. Plain X – ray of the abdomen showed multiple air fluid levels and ultrasound of the abdomen revealed distended bowel loops. On exploration small bowel was found to be gangrenous. The patient was successfully managed by supportive treatment and conventional intravenous Amphotericin-B for 2 weeks. The lady was discharged one week after completion of antifungal therapy and one month later she underwent toilet mastectomy. The lady came to follow up for 1 year and she is currently under hormone therapy. Conclusion With the emergence of new and powerful immunosuppressive, anticancer drugs and potent antibiotics the survival of transplant and critically ill patients has remarkably increased but it has shown a significant rise in the incidence of invasive opportunistic fungal infections. We conclude hat the diagnosis of invasive gastrointestinal aspergillosis may be considered in a neutropenic patient with acute abdominal symptoms.

Study of matrix metalloproteinase-2 in inguinal hernia.

Background Abnormal collagen metabolism is thought to play an important role in the development of primary inguinal and ventral hernia. The detection of an impaired collagen balance both in the tissue as well as in cultured fibroblasts underlines the suspicion that the development of hernia is likely to be implemented primarily by a disturbance of the fibroblast function and their collagen genes. Based on these results we assume that the altered collagen synthesis in hernia patients can be regarded as a genetically linked deregulation serving as a basic initiating or promoting factor for the development of primary inguinal hernias. With the hypothesis that hernia is a local manifestation of a systemic disease manifested by increased expression of matrix metallo-proteinase-2 (MMP-2), a study was planned with following aims: 1) to establish a causal association between inguinal hernia and MMP-2; 2) to test the hypothesis that hernia is a local manifestation of a systemic disorder rather than a mere local mechanical defect. Methods A case control study was conducted on 30 subjects of each direct and indirect inguinal hernia and 30 controls. DAC-ELISA test was used for analysis of serum (preoperative) and tissue samples (fascia transversalis) in patients as well as controls. Results Statistically, serum levels of MMP-2 were significantly increased in all the hernia patients as compared to controls. This increment was maximum in patients of direct hernia. MMP-2 was not detectable in tissue samples. Conclusions Hernia is a local manifestation of a systemic disease rather than a mere local mechanical defect. Keywords MMP-2; Matrix Metalloproteinase-2; Inguinal hernia; DAC-ELISA; Collagen metabolism; PBST-Phosphate Buffer Saline Tween-20

Self-insertion of needles: An unusual cause of empyema thoracis and its thoracoscopic management.

Intrapulmonary aberrant needles are rare in clinical practice. Most common cause till date is the intra-thoracic migration of pins and wires commonly used in treatment of fractures and dislocations of upper extremity. Some cases of traumatic intra-thoracic insertion of needles have also been reported. We report a patient of empyema thoracis due to unusual habit of self-insertion of needles in his body because of some myth. The patient was successfully managed by video-assisted thoracoscopic surgery.

Unusual CT sign of colonic duplication in a child

A 14-month-old child presented with abdominal distension of 6 months duration. US showed ascites with dilated bowel loops. Abdominal CT demonstrated a dilated segment of bowel and a collapsed loop in close apposition (signet ring appearance) to the region of the descending colon (Fig. 1). Laparotomy revealed mucinous ascites and a tubular duplication of the left colon extending from the left third of the transverse colon to the anus. The signet ring appearance was due to a mucin-filled duplicate colon and a collapsed normal colon. Both the signet ring appearance and mucinous ascites were unique features of colonic duplication in this patient. Colonic duplication constitutes 13% of all alimentary tract duplications [1] and is an uncommon anomaly in children; cystic duplications are commoner, tubular duplications being exceedingly rare [2]. The caecum is the commonest site of colonic duplication, followed by the transverse and then the left colon. Presentation is variable, with lower gastrointestinal bleeding, abdominal pain, subacute colonic obstruction or intussusception [3]. Colonic duplication presenting with mucinous ascites or a signet ring appearance seems to be unique. As the duplication itself was full of mucin it is inferred that the ascites resulted from a previous perforation of the duplication that subsequently sealed over. Subacute colonic obstruction was due to the mucin-distended duplication colon compressing the normal descending colon. References

MALT Lymphoma of Caecum Presenting as Acute Intestinal Obstruction: A Case Report

Mucosa-associated lymphoid tissue lymphomas (MALT lymphoma) are well known, but colonic MALT lymphomas are extremely rare. We report the first case of mucosa-associated lymphoid tissue (MALT) lymphoma in the cecum from India presenting as acute intestinal obstruction with mass in right iliac fossa showing diffuse thickening of ascending colon and caecum with obliterated lumen along with nodular mass on CECT scan of abdomen. On video colonoscopy, circumferential ulcerated growth was seen at cecum, and the rest of the colon was normal. Multiple biopsies from growth suggested malignancy. Right hemicolectomy was performed. The histopathology of resected specimen demonstrated low-grade B-cell MALT lymphoma of the cecum, and the depth of invasion was up to the muscular layer. This was confirmed by immunohistochemistry.

Role of lycopene in the prevention of cancer

Cancer is a major public health problem in many parts of the world. There are over 100 different types of cancer, affecting various parts of the body. Oxidative stress is an important contributor in cancer. If oxidative damage is left unrepaired, it can lead to mutations and changes in cell biology, which can lead to neoplasia (unregulated accumulation of cells). Increased consumption of fruits and vegetables has been recommended to reduce the incidence of cancer. Fruits and vegetables are good sources of antioxidants and phytochemicals that mitigate the damaging effect of oxidative stress. They play an important role in the prevention of cancer and maintenance of good health. Recently, there has been a lot of interest in the role of lycopene in cancer prevention. Lycopene is one of the dietary carotenoids and a potent antioxidant. It is present in tomatoes (including processed tomato products) and other fruits such as grape, watermelon, orange, and papaya. Dietary intake of tomato and tomato products containing lycopene has been shown to be associated with decreased risk of cancer. The antioxidant properties of lycopene have been documented as being primarily responsible for its beneficial effects. In this article we outline the possible mechanism of action of lycopene and review the current understanding of its role in cancer prevention.

Varicosity of a single breast: a rare entity

Varicosity of the breasts is a rare clinical entity that may lead to symptoms such as prominent vascular markings over the breasts and may be painless; in long-standing cases it can lead to recurrent bleeding episodes. Bilateral venous affection in the breasts has been described in the literature; however, unilateral affection is a rarely documented phenomenon. Since vascular affliction of a single breast is rare and there is inherent difficulty in obtaining a histopathological diagnosis against a background of suspicion of malignancy, it is always challenging to provide optimal management to the patient. We are reporting a rare case of a 42-year-old, postmenopausal Indian woman with a long-standing history of unilateral varicosity of the left breast, who was treated successfully with a simple mastectomy; postoperative histopathology was consistent with benign vascular lesion, that is, angiomatosis.

Pediatric intestinal leiomyosarcoma

The paper reports an infant presenting with leiomyosarcoma of the small intestine. The patient presented with intermittent abdominal pain. Examination revealed a hard and mobile intraperitoneal mass. The tumor arose from the mid-ileum with regional lymphadenopathy. Excision of the tumor along with the involved bowel was performed followed by three cycles of chemotherapy. Histological diagnosis was that of a low-grade malignant leiomyosarcoma of the small intestine. Surgical excision was followed by three cycles of chemotherapy. After surgery and three cycles of chemotherapy, the patient was followed up for four years with no evidence of recurrence or metastasis. Surgery followed by chemotherapy was curative for leiomyosarcoma in our patient. Intestinal leiomyosarcoma should be kept as a differential diagnosis for mobile solid intraabdominal tumors in childhood.